Provider Demographics
NPI:1235626565
Name:KORSTEN, CELICE
Entity Type:Individual
Prefix:
First Name:CELICE
Middle Name:
Last Name:KORSTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 N. TATUM BLVD. STE. 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028
Mailing Address - Country:US
Mailing Address - Phone:480-678-4193
Mailing Address - Fax:
Practice Address - Street 1:11020 N. TATUM BLVD., STE. 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:480-678-4193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4208103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic